Outcome of reflux therapy on pediatric chronic sinusitis

Association Between Chronic Rhinosinusitis and Reflux Diseases in Adults: A Systematic Review and Meta-Analysis

BACKGROUND

Over the last few decades, reflux diseases, such as laryngopharyngeal reflux (LPR) and gastroesophageal reflux disease (GERD), have been identified as significant contributors to inflammatory upper aerodigestive tract diseases. Establishing a direct relationship between reflux disease and chronic rhinosinusitis (CRS) is challenging due to the high prevalence of both diseases and their potential for independent coexistence.

OBJECTIVE

The purpose of this study is to review the existing literature and evaluate the evidence of an association between reflux diseases and CRS.

METHODS

A comprehensive electronic search was conducted across multiple databases to identify all studies that investigated the relationship between LPR, GERD, and CRS from January 1, 1950, to June 16, 2022. Only studies with English manuscripts involving adult populations were included, while case series, case reports, and in vitro studies were excluded. The risk of bias was evaluated using The Newcastle-Ottawa Scale for case-control studies and the NIH quality assessment tool for observational cohort and cross-sectional studies.

RESULTS

The search strategy yielded a total of 427 articles, out of which 25 studies examined the correlation between reflux diseases and CRS. The meta-analysis indicated a significant association between the presence of GERD and CRS compared to control groups (P < .001; CI 3.56 [2.25, 5.65]), as well as significantly higher pH values and pepsin detection in CRS patients when compared to healthy individuals (P = .003). Furthermore, all studies that evaluated proton pump inhibitor (PPI) therapy in CRS patients reported positive outcomes, with 93% of CRS patients showing improvement on PPIs.

CONCLUSION

The existing literature provides suggestive evidence of an association between reflux diseases and CRS, with regards to both prevalence and treatment. Nonetheless, further studies are required to confirm this relationship.

The management of paediatric rhinosinusitis

Paediatric rhinosinusitis (PDRS) is commonly used as a synonym for rhinitis within healthcare. Although they may share common symptoms, the pathophysiology does differ; PDRS is the inflammation of the nasal mucosa in addition to the sinuses whereas rhinitis is the inflammation of just nasal mucosa. This review provides a comprehensive overview of the epidemiology, pathophysiology, symptoms, diagnosis and management of PDRS. There is a greater emphasis on the diagnosis and management of PDRS within this review due to a lack of clear guidelines, which can lead to the common misconception that PDRS can be treated indifferently to rhinitis and other upper respiratory conditions. PDRS has detrimental effects on children's current health, long-term health into adulthood and education. Therefore, having a comprehensive guide of PDRS would provide a greater understanding of the condition as well as improved diagnosis and management. This article primarily focuses on the position of Europe and the United Kingdom; however, the recommendations can be applied to other countries as the causes and treatments would not differ significantly.

Extraesophageal signs of gastroesophageal reflux disease: otorhinolaryngologist’s view

The data on association between various pathologies of the ENT organs and gastroesophageal reflux disease (GERD) is analysed in the article. The variety of extraesophageal signs of GERD in children and adults is given, what is advisable to inform physicians of different specialties about the possibilities of antireflux therapy. These options are expanded with the emergence of a unique new drug, Alfasoxx. Its bioadhesive formula is based on hyaluronic acid and chondroitin sulphate thereby protecting the esophageal mucosa. Alfasoxx acts on the surface of the esophageal mucosa without penetrating into the systemic bloodstream and it also has a low allergenic potential, which has been confirmed by numerous studies. With its healing and repairing effect on erosive lesions of the esophageal epithelium, Alfasoxx in combination with proton pump inhibitors is more effective in achieving regression of clinical manifestations of the disease and improving patients quality of life (according to SF-36 questionnaire) compared to proton pump inhibitors monotherapy.

Outcome of Gastroesophageal Reflux Therapy in Children with Persistent Otitis Media with Effusion

Introduction Otitis media with effusion (OME) is considered one of the most common disorders that affect children during the first years of life. There are many risk factors of persistent middle ear effusion; one of these risk factors is gastroesophageal reflux. Association between persistent OME and gastroesophageal reflux diseases (GERDs) could be explained by respiratory tract infections, insufficient ciliary clearance, and poor drainage of the Eustachian tube.

Objective To investigate whether the control of gastroesophageal reflux plays a role in the management of persistent OME and decreases tympanostomy tube insertion

Method A cross-sectional study was conducted on 50 children complaining of persistent OME. Their ages ranged between 5 and 12 years old. All children were subjected to full history taking, audiological assessment and 24-hour esophageal pH monitoring. The study group was divided according to pH results into two groups: GERD positives and GERD negatives.

Result The prevalence of GERD in persistent OME was 58%. There were statistically significant differences in the hearing levels and middle ear condition before and after the treatment (p < 0.05). The percentage of improvement of children complaining of persistent OME after antireflux treatment was 52%.

Conclusion Gastroesophageal reflux disease should be considered in patients with persistent OME. The administration of proton pump inhibitor (PPI) can set aside superfluous surgical treatment (such as tympanostomy).

Gastritis and gastroesophageal reflux disease are strongly associated with non-allergic nasal disorders

Background

Gastroesophageal reflux disease (GERD) has been reported to be significantly associated with chronic rhinosinusitis, but the strength of the association is still debated.

Aims

To evaluate the strength of the association between gastritis/GERD and non-allergic rhinitis (NAR)/allergic rhinitis (AR)/sinusitis.

Methods

We investigated 2887 subjects aged 20–84 years, who underwent a clinical visit in seven Italian centres (Ancona, Palermo, Pavia, Terni, Sassari, Torino, Verona) within the study on Gene Environment Interactions in Respiratory Diseases, a population-based multicase-control study between 2008 and 2014. Subjects were asked if they had doctor-diagnosed “gastritis or stomach ulcer (confirmed by gastroscopy)” or “gastroesophageal reflux disease, hiatal hernia or esophagitis”. The association between NAR/AR/sinusitis and either gastritis or GERD was evaluated through relative risk ratios (RRR) by multinomial logistic regression.

Results

The prevalence of gastritis/GERD increased from subjects without nasal disturbances (22.8% = 323/1414) to subjects with AR (25.8% = 152/590) and further to subjects with NAR (36.7% = 69/188) or sinusitis (39.9% = 276/691). When adjusting for centre, sex, age, education level, BMI, smoking habits and alcohol intake, the combination of gastritis and GERD was associated with a four-fold increase in the risk of NAR (RRR = 3.80, 95% CI 2.56–5.62) and sinusitis (RRR = 3.70, 2.62–5.23) with respect to controls, and with a much smaller increase in the risk of AR (RRR = 1.79, 1.37–2.35)..

Conclusion

The study confirmed the association between gastritis/GERD and nasal disturbances, which is stronger for NAR and sinusitis than for AR.

A 10-Year Follow-Up of a Randomized Prospective Study of 2 Treatments for Chronic Rhinosinusitis Without Nasal Polyps and Investigation of the Impact of Gastroeosophageal Reflux Disease in the Resistance to Treatment

OBJECTIVES

To compare the 2 long-term medical strategies in chronic rhinosinusitis without nasal polyps (CRSnNP) and to identify the role of gastroesophageal reflux disease (GERD) and Helicobacter pylori as factors of treatment failure.

MATERIAL AND METHODS

Fifty-seven patients with CRSnNP were randomized into 2 therapeutic groups. The first group was treated with 4 weeks of amoxicillin/clavulanate and a short course of oral steroids. The second group received 8 weeks of clarithromycin. Sinonasal Outcome Test-20 (SNOT-20) and Lund and Mackay scores were assessed at baseline and after treatment, and GERD Health-Related Quality of Life (GERD-HRQL) questionnaire was evaluated in all patients. Patients with a GERD-HRQL score >8 received esogastroscopy and H pylori detection. Patients were followed during a 10-year period for clinical course and GERD evolution. The 10-year evolution of patients was described in terms of recurrence, medical, and surgical treatments.

RESULTS

Thirty-seven patients completed the study; SNOT-20 and Lund and Mackay scores similarly improved in both groups. Amoxicillin/clavulanate group had significantly more adverse reactions than the clarithromycin group (P = .03). After the therapeutic course, 35% (amoxicillin/clavulanate) and 41% (clarithromycin) of patients needed functional endoscopic sinus surgery (FESS). During the long-term follow-up, 54% (amoxicillin/clavulanate) and 40% (clarithromycin) of patients had late CRSnNP recurrence; FESS was performed in less than 15% of cases of recurrence. Gastroesophageal reflux disease complaint's severity was associated with late recurrence of CRSnNP.

CONCLUSION

Amoxicillin/clavulanate and clarithromycin would be competitive treatments for CRSnNP. Gastroesophageal reflux disease seems to be a negative factor for treatment response and recurrence.

A Clinical Trial of Proton Pump Inhibitors to Treat Children with Chronic Otitis Media with Effusion

OBJECTIVE

Gastroesophageal reflux (GER) is considered a cause of otitis media with effusion (OME). This study aimed to investigate whether OME can be effectively treated with a proton pump inhibitor (PPI), therefore implicating GER as a causative factor of OME.

MATERIALS AND METHODS

A PPI or placebo was randomly administered to enrolled subjects for 4-8 weeks. To monitor effusion status, subjects underwent monthly pneumatic otoscopy and acoustic reflectometry. At enrollment and at completion of treatment, subjects underwent an audiogram and tympanogram for assessing changes in hearing due to altered fluid levels in the middle ear. After the treatment period, tympanostomy tube placement was recommended for subjects with unresolved effusion.

RESULTS

This study enrolled 16 patients with an average age of 5.17 years. Between the treatment and placebo groups, there was no significant difference in the need for tympanostomy tubes. At completion of this study, patients receiving Lansoprazole demonstrated a significant improvement in pure tone average (p<0.01) and speech recognition thresholds (p=0.04). Four patients (25%) from the cohort dropped out of the study. Eight patients (50%) from the cohort required tympanostomy tube placement.

CONCLUSION

Owing to difficulties with recruitment and small sample size, this study was unable to demonstrate the use of PPI in treating OME. A larger study is needed for further evaluation of this process.

Human Lung Mucous Glands Manifest Evidence of the H+/K+-ATPase Proton Pump

Objectives:

The H+/K+-ATPase proton pump has been demonstrated in human laryngeal submucosal glands, and is not solely present in the parietal cells of the stomach. Although proton secretion is present in the lung, a variety of mechanisms have been elucidated. The hypothesis of this study is that the H+/K+-ATPase proton pump is one additional pathway of proton secretion in the human lung.

Methods:

Fourteen surgical lung specimens from 10 subjects were retrospectively obtained after approval from our Human Subjects Committee. Banked human stomach tissue was used for comparative positive and negative controls. Sections were immunostained with 2 monoclonal antibodies selectively reactive with alpha or beta subunits of the H+/K+-ATPase proton pump.

Results:

In the human lung, consistent staining for both subunits was present in the mucous gland cells and ducts in all specimens in which mucous glands were present (6 specimens from 5 subjects). Overall, weak to strong staining was present in focal areas within the multicellular mucous glands. There was only scant focal staining in the respiratory epithelium in 4 specimens. Stomach parietal cells exhibited strongly positive staining for both subunits of the proton pump. There was no staining in stomach cells that were not morphologically consistent with parietal cells.

Conclusions:

The H+/K+-ATPase proton pump is present in mucous cells and ducts in the human lung, with some variable expression noted. Proton pump inhibitor pharmacotherapy may have a site of action in the human lung, explaining some of the controversies otherwise attributable to interrelatedness of aerodigestive tract disease.

Helicobacter Pylori and Laryngopharyngeal Reflux in Chronic Rhinosinusitis

OBJECTIVES: Investigation of the potential role of several laryngopharyngeal reflux contents in sinus disease.

STUDY DESIGN AND SETTING: A controlled cohort analysis of Helicobacter pylori, pepsin and pepsinogen I in inflamed and non-inflamed sinonasal tissue. Fifteen patients, selected for surgery due to chronic medically refractory rhinosinusitis, had their pathologic sinus tissue analyzed for polymerase chain reaction detection of H. pylori DNA and assayed for pepsin and pepsinogen I tissue concentration levels. A control group of 5 patients undergoing surgery for anatomic sinonasal abnormalities provided non-inflammatory mucosa specimens for comparison.

RESULTS: H. pylori was found scattered in inflamed and non-inflamed mucosa, whereas sinonasal tissue pepsin/pepsinogen never rose above blood levels in both groups.

CONCLUSIONS: Evidence of intra-operative peptic reflux into the sinuses was not found. As H. pylori was similarly encountered in healthy and diseased sinus mucosa, it seemingly fails to support a pathogenic role for this organism in the sinuses.

EBM rating: B-2b

Prevalence and characteristics of gastroesophageal reflux in children with otitis media in Isfahan, Iran

BACKGROUND

Otitis media (OM) is the most common cause of childhood hearing loss and reason to visit the pediatrician. Furthermore, gastroesophageal reflux (GER) has been associated with a variety of upper aerodigestive tract symptoms or diseases, such as sinusitis, laryngitis, and otits. The objective of the present study was to determine the frequency of GER in children, aged 3 months to 7 years, with OM.

MATERIALS AND METHODS

This retrospective case-control study was conducted on 50 children with OM and 50 healthy children. Presence of GER as the main variables was diagnosed by clinical examination in all studied children using the questionnaires with 2 age-stratified versions of the pediatric GER disease symptoms for children 2 years old and younger, and children 3-7 years old.

RESULTS

The prevalence of GER in children with OM and controls was 58% and 22% respectively (P = 0.0005). The frequency of irritability, congestion, and feeding complex in children with OM were significantly more than in control groups. Among children with recurrent acute OM (AOM), and chronic serous OM (CSOM) the prevalence of GER was significantly more than controls (61.1%, vs. 22% for AOM, P = 0.004, and 72.7% vs. 22%, P= 0.003). In children with AOM, regurgitation, vomiting, irritability and congestion were significantly higher than controls included. In children with CSOM, regurgitation, vomiting, and congestion were significantly higher than controls.

CONCLUSION

Results show a significant association between GER and OM, AOM and CSOM in children with OM compares to healthy children. This shows that looking for GER in children with OM may help improving treatments outcomes.

Extra-Esophageal Pepsin from Stomach Refluxate Promoted Tonsil Hypertrophy

Background

Gastroesophageal reflux is associated with numerous pathologic conditions of the upper aerodigestive tract. Gastric pepsin within reflux contributes to immunologic reactions in the tonsil. In this study, we aimed to find the relationships between pepsin and tonsillar hypertrophy.

Methods and finding

We explored the notion whether tonsillar hypertrophy was due to pepsin-mediated gastric reflux in tonsil hypertrophy. Fifty-four children with tonsil hypertrophy and 30 adults with tonsillitis were recruited before surgical treatment. Blood and tonsil tissues from each patient were harvested for analysis of changes in lymphocyte and macrophage numbers coupled with histological and biochemical analysis. Pepsin was expressed at different levels in tonsil tissues from each tonsillar hypertrophy. Pepsin-positive cells were found in the crypt epithelium, surrounding the lymphoid follicle with developing fibrosis, and also surrounding the lymphoid follicle that faced the crypt. And also, pepsin staining was well correlated with damaged tonsillar squamous epithelium and TGF-β1 and iNOS expression in the tonsil section. In addition, pepsin and TGF-β1-positive cells were co-localized with CD68-positive cells in the crypt and surrounding germinal centers. In comparison of macrophage responsiveness to pepsin, peripheral blood mononuclear cells (PBMNCs) were noticeably larger in the presence of activated pepsin in the child group. Furthermore, CD11c and CD163-positive cells were significantly increased by activated pepsin. However, this was not seen for the culture of PBMNCs from the adult group.

Conclusions

The lymphocytes and monocytes are in a highly proliferative state in the tonsillar hypertrophy and associated with increased expression of pro-inflammatory factors as a result of exposure to stomach reflux pepsin.

Adenoid hypertrophy and chronic rhinosinusitis: Helicobacter pylori on antral lavages, adenoid tissue and salival inmunoglobuline A on paediatric patients

OBJECTIVE

To determine Helicobacter pylori presence on antral lavages, adenoids and salival inmunoglobuline A on paediatric patients with chronic rhinosinusitis without nasal polyps (CRSsNP) and adenoid hypertrophy.

METHODS

Adenoid tissue, liquid obtained from antral lavages and saliva from 28 children diagnosed with CRSsNP, from the paediatric otorhinolaryngology practice of "Dr. Domingo Luciani" Hospital was taken and processed by means of polymerase chain reaction (PCR) using cagA, vacA and babA primers, also anatomopathological examination using Giemsa stain of the adenoids, determination of salivary specific secretory inmunoglobuline A (sIgA), socio-economic condition using the Graffar scale and associated gastrointestinal symptoms were assessed.

RESULTS

No evidence of Helicobacter pylori neither in antral lavages liquid nor adenoid tissue was found using PCR and Giemsa stain. sIgA was present in 28.6% of the subjects. The most frequently found symptoms were, diarrhea in 17.9%, distension and abdominal pain in 10.7%, 64.3% of the patients were in working (28.6%) and low middle (35.7%) classes.

CONCLUSIONS

Helicobacter pylori is not present neither in maxillary sinuses nor adenoid tissue of the evaluated patients, sIgA it is a non-invasive method for assessment of immunologic challenge with the bacteria, not the presence of acute or chronic infection.

Epidemiology of chronic rhinosinusitis, selected risk factors, comorbidities, and economic burden

Chronic rhinosinusitis (CRS) is a relevant and prevalent medical condition in Germany, Europe and the world. If analysed in detail, the prevalence of CRS shows regional and temporary variety. In this review, currently available data regarding the prevalence of CRS is therefore sorted by country and/or region, time point of data collection and the CRS-definition employed. Risk factors like smoking and gastroesophageal reflux are discussed regarding their influence on CRS prevalence. Moreover, comorbidities of CRS, like asthma, conditions of the cardiovascular system and depression are listed and their influence on CRS is discussed. Furthermore, data on CRS prevalence in special cohorts, like immunocompromised patients, are presented. To estimate the economic burden of CRS, current data e.g. from Germany and the USA are included in this review.

An evaluation of olfactory function in adults with gastro-esophageal reflux disease

CONCLUSION

To the best of the authors' knowledge, this study is the first to evaluate the olfactory function of adult patients diagnosed with GERD. The results revealed that adults with GERD have diminished olfactory function.

OBJECTIVE

This study aimed to evaluate the olfactory abilities of subjects using the 'Sniffin' Sticks' olfactory test.

METHODS

A total of 35 men and women aged 18-60 years with a diagnosis of GERD and 45 healthy controls were included in the study. The Sniffin' Sticks olfactory test results of the two groups were compared, and the relationship between the study findings and the olfactory parameters was evaluated.

RESULTS

The odor threshold (10.1; 9.5, p = 0.016), odor identification (9.6; 8.1, p < 0.001), and odor discrimination (10.7; 8.9, p < 0.001) of the GERD group were significantly lower than those of the control group. A statistically significant positive correlation was detected between the accompanying chronic pharyngitis, chronic sinusitis, and odor parameters. A significant correlation was not detected between the laryngeal findings and the olfactory parameters.

Familial risk of pediatric chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

To determine the risk of chronic rhinosinusitis (CRS) in relatives of children with a diagnosis of CRS.

STUDY DESIGN

Retrospective observational cohort study with population-based matched controls.

METHODS

A unique genealogical database linked to medical records was used to identify subjects ≤12 years old with a diagnosis of CRS from 1996 to 2011. The familial recurrence risks of CRS in first- through fifth-degree relatives of probands were calculated using Cox models and compared to controls randomly selected from the Utah population and matched 10:1 on sex and birth year.

RESULTS

We identified 496 pediatric patients with CRS. Siblings of patients with CRS demonstrated a 57.5-fold increased risk (P < 10(-8) ) of also having pediatric CRS. First cousins had a 9.0-fold increased risk (P < 10(-3) ) and second cousins had a 2.9-fold increased risk (P = .002) of pediatric CRS. First-degree relatives, second-degree relatives, and first cousins of pediatric cases demonstrated a significant increased risk of having adult CRS. Parents of probands demonstrated a 5.6-fold increased risk (P < 10(-15) ). Fifty-five probands had one affected parent versus three probands with two affected parents.

CONCLUSIONS

In the largest population study to date of children with CRS, a significant familial risk is confirmed. Parents of probands were also at increased risk, although it was much more likely for one parent to be affected than both, suggesting a genetic component of the disease. Further understanding of the genetic basis of CRS and its interplay with environmental factors could clarify the etiology and lead to more effective targeted treatments.

LEVEL OF EVIDENCE

3b Laryngoscope, 126:739-745, 2016.

Role of Laryngopharyngeal Reflux in Complications of Tonsillectomy in Pediatric Patients

Tonsillectomy and tonsillectomy with adenoidectomy are among the most common surgical procedures in otolaryngology practice. Gastroesophageal reflux was identified as a risk factor for complications in tonsillectomy. This prospective study was designed to assess the role of reflux in the development of complications following tonsillectomy in pediatric patients. Children (n = 60) who underwent tonsillectomy with adenoidectomy were divided into two groups, i.e., the laryngopharyngeal reflux (LPR) group and control group. Patients with LPR were identified by reflux symptom index and reflux finding score. Pain, hemorrhage, fever, nausea, vomiting, fever, dehydration, infection, and pulmonary problems were evaluated post operatively. The mean lengths of hospital stay were 2.11 days in the reflux group and 1.05 days in the control group. The difference was statistically significant. Visual analogue scores of both groups were similar on day 1 but it was significantly higher on day 7 and 14 in LPR group. Nausea and vomiting rates were 11.1 and 9.5 % for the patients in the LPR group and the controls, respectively. The difference between the two groups was not significant. The mean fever was 37.6 °C in the reflux group and 37.3 °C in the controls, which were not significantly different. 19 % of the controls and 22 % of the LPR group patients were readmitted. This difference was not statistically significant. There were two cases of bleeding in the reflux group, while no bleeding occurred in the control group. This difference was significant statistically. LPR is a risk factor for complications following tonsillectomy.

Diseases of the nose and paranasal sinuses in child

Diseases of the pediatric nose and nasal sinuses as well as neighboring anatomical structures encompass a variety of pathologies, especially of inflammatory nature. Congenital disease, such as malformations and structural deviations of the nasal septum, as well as systemic metabolic pathologies affecting the nose and sinuses, rarely require medical therapy from an Otolaryngologist. The immunological function of the mucosa and genetic factors play a role in the development of disease in the pediatric upper airway tract, especially due to the constantly changing anatomy in this growth phase. Disease description of the nose and nasal sinuses due to mid-facial growth must also take developmental age differences (infant, toddler, preschool, and school age) into account. Epidemiological examinations and evidence based studies are often lacking in the pediatric population. The wide range of inflammatory diseases of the nose and paranasal sinuses, such as the acute and chronic rhinosinusitis, the allergic rhinitis, and adenoid disease, play a role in the susceptibility of a child to infection. The susceptibility to infection depends on the pediatric age structure (infant, young child) and has yet to be well defined. The acute rhinosinusitis in children develops after a viral infection of the upper airways, also referred to as the "common cold" in the literature. It usually spontaneously heals within ten days without any medical therapy. Antibiotic therapy is prudent in complicated episodes of ARS. The antibiotic therapy is reserved for children with complications or associated disease, such as bronchial asthma and/or chronic bronchitis. A chronic rhinosinusitis is defined as the inflammatory change in the nasal mucosa and nasal sinus mucosa, in which the corresponding symptoms persist for over 12 weeks. The indication for CT-imaging of the nasal sinuses is reserved for cases of chronic rhinosinusitis that have been successfully treated with medication. A staged therapeutic concept is followed in CRS based on conservative and surgical methods. Nasal sinus surgery is considered nowadays as effective and safe in children. Based on the assumption that adenoids are a reservoir for bacteria, from which recurrent infections of the nose and nasal sinus originate, the adenoidectomy is still defined as a cleansing procedure in rhinosinusitis. 69.3% of the children had benefit from adenoidectomy. Comorbidities, such as pediatric bronchial asthma, presently play an even more important role in the therapy of rhinosinusitis; therefore, it is often wise to have the support of pediatricians. In western European countries 40% of children presently suffer from allergic rhinitis, in which pronounced nasal obstruction can cause disturbed growth in facial bones. An early therapy with SIT may prevent the development of bronchial asthma and secondary sensitization to other allergens. Therefore, SIT is recommended in treatment of allergic rhinitis whenever, if possible. The assessment of diagnostic tools is for the examiner not often possible due to the lack of evidence. Rhinosurgical approaches are often described in study reports; however, they lack the standard prospective randomized long-term study design required nowadays and can only be evaluated with caution in the literature.

Pediatric chronic rhinosinusitis

Pediatric chronic rhinosinusitis is a multifactorial inflammatory and infectious disorder. It likely reflects a dysfunction at the site of the interaction between host and environmental factors in the nose and sinuses. Our limited understanding of this common childhood disease makes it difficult to diagnose and to treat effectively. This review focuses on the scope of manifestations particular to the pediatric form of the disease, diagnostic challenges, and epidemiologic data. The normal development of sinuses in children, the role of inflammation, and biofilm and immune responses in the pathophysiology of chronic rhinosinusitis in pediatric patients are discussed. Predisposing and comorbid factors contributing to this disorder or associated with it are described. The current investigational and therapeutic approaches are presented, including recommendations for imaging and medical and surgical therapy. Various aspects of the disease that are still subject of controversy are underscored. Advice for what constitutes a reason to involve a multidisciplinary collaboration in the care of a child with chronic rhinosinusitis is provided.

Chronic rhinosinusitis and age: is the pathogenesis different?

Chronic rhinosinusitis (CRS) is a common disease with a significant impact on quality of life, which is seen across all age groups. There are differences in symptomatology, histopathology and associated diseases when comparing pediatric versus adult patients with CRS. Nasal polyposis tends to be less commonly seen in pediatric CRS compared with adults except in children with cystic fibrosis or allergic fungal rhinosinusitis. The differences in histopathology of CRS in different age groups include higher cellularity and more prominent lymphocytic infiltration in children compared with adults who tend to have a stronger eosinophilic infiltration and more prominent glandular hyperplasia. There are data supporting a stronger association of gastroesophageal reflux disease and otitis media with CRS in children compared with adults. Adenoids may play a role in pediatric, but not adult CRS. Immunodeficiencies and asthma are strongly associated with CRS in all age groups. There is a paucity of data on pathophysiology of disease on elderly CRS.

Chronic rhinosinusitis in children

Chronic rhinosinusitis (CRS) affects nearly 37 million people in the United States each year and accounts for approximately $6 billion in direct and indirect health care costs. Despite its prevalence and significant impact, little is known about its exact cause and pathophysiology, and significant controversy remains regarding appropriate treatment options. Basic science research, however, has shown recent promise toward improving understanding of the innate and environmental factors underlying the pathophysiology of CRS. The hope is that this will also lead to advances in treatment for children adversely affected by this common yet complicated disease.

Gastroesophageal reflux and rhinosinusitis

Gastro-esophageal reflux disease (GERD) and chronic rhino-sinusitis (CRS) are prevalent disorders. Coexistence by chance is to be expected in a number of patients. Coexistence due to shared pathogenic mechanisms is controversial. In this paper, we have described the characteristics of GERD and CRS epidemiologically, diagnostically, and pathophysiologically, and reviewed the existing data about a potential role of gastro-esophageal reflux (GER) in the pathogenesis of CRS. A causal link between GERD and CRS has so far not been sufficiently documented. However, some studies do indicate a correlation. Hence, anti-reflux measures should be considered as an option in CRS, particularly in patients where conventional medical and surgical treatment is insufficient.

Applying principles of physics to the airway to help explain the relationship between asthma and gastroesophageal reflux

Gastroesophageal reflux (GER) and asthma have been linked, but the true nature of this relationship is incompletely understood. Most of the literature examining this association has implicated GER as the factor contributing to asthma. GER has also been linked to conditions of the upper airway like sinusitis and obstructive sleep apnea (OSA), and once again, usually presumed to be the causative factor. While GER seems to be capable of exacerbating airway disease, mounting evidence suggests that airway obstruction is a risk factor for developing GER. This article examines the principles of physics that predict what should occur given the anatomy of the airway and the esophagus, and provides multiple examples of disease associations that appear to support the hypothesis that airway obstruction is a significant risk factor for development of gastroesophageal reflux.

Does gastroesophageal reflux contribute to development of acquired nasolacrimal duct obstruction?

Primary acquired nasolacrimal duct obstruction results from inflammation of unknown cause that eventually leads to fibrosis and occlusion. The nasolacrimal duct is within the medial wall of maxillary sinus and open into the nasal cavity. It may be affected by gasteroesophageal reflux disease (GERD) by the possible direct noxious effect of the refluxate on the nasal mucosal cavity surrounding of the nasolacrimal duct opening at the inferior meatous and ascending of inflammation to the mucosa of the duct may leads to chronic inflammation and fibrosis. In addition to, the GERD may induce autonomic nervous system hyperactivity resulting in hyperemia of venous plexus surrounding nasolacrimal duct leading to secondary mucosal edema of nasolacrimal duct and dacryostenosis.

Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)

OBJECTIVE

To develop a North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) international consensus on the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

METHODS

An international panel of 9 pediatric gastroenterologists and 2 epidemiologists were selected by both societies, which developed these guidelines based on the Delphi principle. Statements were based on systematic literature searches using the best-available evidence from PubMed, Cumulative Index to Nursing and Allied Health Literature, and bibliographies. The committee convened in face-to-face meetings 3 times. Consensus was achieved for all recommendations through nominal group technique, a structured, quantitative method. Articles were evaluated using the Oxford Centre for Evidence-based Medicine Levels of Evidence. Using the Oxford Grades of Recommendation, the quality of evidence of each of the recommendations made by the committee was determined and is summarized in appendices.

RESULTS

More than 600 articles were reviewed for this work. The document provides evidence-based guidelines for the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

CONCLUSIONS

This document is intended to be used in daily practice for the development of future clinical practice guidelines and as a basis for clinical trials.

Recurrent acute otitis media and gastroesophageal reflux disease in children. is there an association?

OBJECTIVE

To investigate whether there is a relationship between gastroesophageal reflux disease (GERD) and recurrent acute otitis media (RAOM) in infants and children. Possible risk factors are also explored.

MATERIAL AND METHODS

221 consecutive children who had symptoms and signs associated with GERD and had undergone a prolonged ambulatory 24-h esophageal pH-monitoring. Thirty-four children were excluded from the study due to age, neurological deficits, congenital abnormalities, immunodeficiency syndromes or other chronic systemic disorders. The remaining 187 children (96 boys and 91 girls), aged between 40 days and 33 months (mean age of 18.3 months) were assigned into three groups according to their Reflux Index (RI%). Group A: 49 children (26.2%) without GERD (control group); Group B: 78 children (41.7%) with low to moderate RI; and Group C: 60 children (32.1%) with severe GERD. Parental interviews and personal medical files of the National Health System were used for data collection. However, episodes of acute otitis media were taken into account only if they were diagnosed by a physician. The follow-up period ranged from 6 to 8 years in order to cover the peaks of otitis media incidence in childhood.

RESULTS

The results revealed that 6 children from Group A (12.24%), 11 from Group B (14.1%) and 19 from Group C (31.67%) presented episodes of RAOM. The difference was statistically significant (p=0.01). Furthermore, in children who received anti-reflux treatment, the incidence of RAOM substantially decreased and eventually became approximate to that of the control Group A (12.32%). Logistic regression revealed that the strongest risk factor for recurrent otitis media was severe GERD (odds ratio, 4), then attendance at day-care centres (odds ratio, 3), followed by allergies (odds ratio, 2.7).

CONCLUSIONS

Severe GERD could be implicated in the multifactorial etiology of RAOM in infants and children.

Correlation between nasal mucociliary clearance time and gastroesophageal reflux disease: our experience on 50 patients

OBJECTIVES

It is increasingly suggested that gastroesophageal reflux disease (GERD) could play an important role in chronic rhinosinusitis. The aim of our study was to evaluate the nasal mucociliary clearance time in GERD patients and if any correlations could be assumed.

METHODS

Fifty GERD patients endoscopically diagnosed underwent an ear, nose and throat evaluation. The saccharin test and the 20-Item Sino-nasal Outcome Test (SNOT-20) were administered to 50 participants who correspond to our inclusion criteria. The saccharin test is a validated proof to verify the nasal mucociliary clearance time and the SNOT-20 is a disease-specific, health-related quality of-life questionnaire widely used for the assessment of rhinosinusitis.

RESULTS

Thirty-seven (74%) patients showed a significant increment in their saccharin test values in comparison with the others subjects (23.79+/-5.58 vs 8.15+/-2.06min; P=0.0001). This group of patients reported only typical gastroesophageal symptoms (GES) without any other complaint. Gastroesophageal endoscopic findings revealed some interesting and unexpected results in this subgroup. The remainder of patients considered (13/50; 26%) showed normal values for nasal mucociliary clearance time and they referred only typical extraesophageal symptoms (EES). In any case and in both groups rhinosinusitis complaints were present. The SNOT-20 test results were normal in all patients even if a significant difference for GES group could be highlighted (19.3 vs 7.4; P<0.005).

CONCLUSION

This study supports the assumption of possible and important correlations between nasal mucociliary clearance time and GERD. GERD could be an altering factor for nasal function also in absence of laryngo-pharyngeal symptoms although to verify this interesting hypothesis more validated data are necessary.

The impact of extra-esophageal reflux upon diseases of the upper respiratory tract

PURPOSE OF REVIEW

The present paper examines the recent literature on extra-esophageal reflux and discusses how it affects patient testing and treatment of upper respiratory track inflammatory disease.

RECENT FINDINGS

Assays for pepsin have been developed casting more insight into the pathophysiology of extra-esophageal reflux as well as looking at the role of protective factors in upper respiratory mucosa. Similarities and differences in esophageal and extra-esophageal reflux continue to be explored. Acid suppression in extra-esophageal reflux improves symptoms before physical findings, but some patients do not respond. Mildly acidic (pH > 4) and alkaline reflux are being examined more in extra-esophageal reflux with impedance testing playing a more prominent role. Recent studies have also focused on whether extra-esophageal reflux could affect tissues of the nasopharynx, sinuses, or middle ear. Caution has been issued as acid suppressive therapies have been associated with hip fracture in older patients.

SUMMARY

Symptoms caused by reflux may reflect underlying weaknesses in mucosal resilience to acid and pepsin in addition to the variations in exposure to gastric contents. In some patients mildly acidic or alkaline reflux may be important and gastric contents may reach the nasopharynx or middle ear. Carefully designed placebo-controlled trials are needed.

Nasal pepsin assay and pH monitoring in chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

The primary objective of this study was to determine the relationship between chronic rhinosinusitis (CRS) and laryngopharyngeal reflux (LPR). We also investigated the diagnostic value of pepsin in nasal lavage by means of fluorometric assay as compared with 24-hour dual-probe pH monitoring.

STUDY DESIGN AND METHODS

This is a controlled, prospective study from a retrospective dataset of 33 patients recruited for endoscopic sinus surgery between 2005 and 2006 in a tertiary care referral center (Hacettepe University Medical Center). All patients underwent 24-hour dual-probe pH monitoring and nasal lavage fluid investigation for pepsin. A fluorometric pepsin assay using casein-fluorescein isothiocyanate in nasal lavage fluid was used to detect LPR. The control group included 20 patients who were proven not to have sinusitis.

RESULTS

A higher incidence of pharyngeal acid reflux events was found in patients with CRS (29 of 33, 88%) compared with the control patients (11 of 20, 55%). The difference was statistically significant (P = .01). The fluorometric pepsin assay was correlated to the results of 24-hour dual-probe monitoring for LPR diagnosis with a 100% sensitivity and 92.5% specificity. These data suggest that an association between CRS and LPR is present and that the detection of pepsin in nasal lavage fluid may provide a noninvasive and feasible method of LPR screening.

Laryngopharyngeal reflux: diagnosis and treatment of a controversial disease

PURPOSE OF REVIEW

Laryngopharyngeal reflux is a well-recognized and widely used term in ear, nose and throat practice. However, the symptoms and signs attributed to laryngopharyngeal reflux are non-specific and treatment is usually empirical. This review discusses current knowledge on diagnosis and treatment of laryngopharyngeal reflux.

RECENT FINDINGS

Information is evolving regarding the implications of laryngopharyngeal reflux in the development of pathological conditions affecting the upper aerodigestive tract epithelium such as chronic laryngitis, otitis media with effusion and chronic sinusitis. However, there is still much to learn about the pathophysiologic mechanisms of laryngopharyngeal reflux and their role in its related disease conditions and there is still considerable controversy on diagnostic as well as therapeutic parameters for this condition. There is no consensus on the diagnosis and treatment of laryngopharyngeal reflux and the majority of clinicians depend mainly on clinical findings and empirical therapeutic tests rather than more specific investigations.

SUMMARY

The concept of laryngopharyngeal reflux is still controversial. The current practice of empirical treatment with proton-pump inhibitors is based on weak evidence. However, this practice seems to be widely accepted and will not change until further clinical and laboratory studies improve our understanding of this common and well-recognized condition.

Extra-esophageal acid reflux induced adenotonsillar hyperplasia: case report and literature review

The etiology of adenotonsillar hyperplasia is not well understood. A 3-year-old child presented with obstructive sleep apnea believed to be secondary to enlarged tonsils and adenoids. Subglottic stenosis was encountered during intubation; the adenotonsillectomy was cancelled. Severe extra-esophageal reflux was identified and treated. At follow-up endoscopy 3 weeks later, the tonsils and adenoids were no longer enlarged or obstructing the airway. The role of extra-esophageal reflux in the pathogenesis adenotonsillar hyperplasia is discussed.

Monitoring of gastric acid suppression in patients with extraesophageal reflux disease

OBJECTIVE

Response to acid suppressive therapy varies in patients with extraesophageal esophageal reflux disease (EERD). Inadequate suppression of gastric acid may contribute to the observed differences in the response to the treatment. The aim of this study was to evaluate suppression of gastric acid in EERD patients being treated with acid suppressive therapy.

METHODS

Charts of patients with EERD who underwent dual channel 24h esophageal pH monitoring while receiving acid suppressive therapy between January 2002 and June 2004 were reviewed. Suppression of gastric acid was determined based on the number of acid reflux episodes, esophageal acid exposure, and acid clearance time.

RESULTS

Twenty patients (12 male, 8 female, age range: 2-19 years) were identified. Esophageal pH monitoring was within normal limits, documenting complete acid suppression in nine patients (45%). Increased numbers of acid reflux episodes were observed in seven patients. In four patients, the number of acid reflux episodes was normal in spite of incomplete acid suppression. However, other abnormal pH monitoring parameters included delayed acid clearance in three patients and increased acid exposure time in three. The majority of patients also showed alkaline reflux.

CONCLUSION

Esophageal pH monitoring documented incomplete acid suppression in this group of infants, children, adolescents and teens with EERD. Monitoring of gastric acid suppression can be useful in guiding the follow-up of EERD patients who receive acid suppressive therapy.

Laryngopharyngeal reflux and chronic sinusitis

In patients with chronic and recurrent sinusitis, laryngopharyngeal reflux disease may play a significant role. Laryngopharyngeal reflux disease differs from gastroesophageal reflux disease in the extent of reflux (into the hypopharynx and above) as well as timing (occurring more often when the patient is upright). Most patients are unaware of the extent of their symptoms, and diagnostic tools such as pH probe, multichannel intraluminal impedance, and manometry are required for adequate diagnosis. Although therapy with lifestyle modification and acid-suppressive agents may improve reflux in the majority of patients, for many with persistent symptoms, endoscopic or surgical intervention is required to reduce reflux successfully.

Nonallergic rhinitis in children

Nonallergic rhinitis in children is a medical condition that has not been well defined and the true incidence is unknown. Current treatment recommendations are based on data obtained from adult studies. The mechanisms of pediatric nonallergic rhinitis are also unclear. The concept that laryngopharyngeal reflux (LPR) events may play a critical role in the pathogenesis of upper airway disease is presently under investigation. Although LPR is being better delineated and appropriate methods of diagnosis and treatment are being studied, substantial evidence links LPR with several disease states including rhinitis, sinus disease, and middle ear disease. Due to the lack of information concerning the etiology of nonallergic rhinitis in children, LPR should be considered in the differential diagnosis of a child with negative skin tests and chronic rhinitis symptoms. The clinician should especially give attention to this diagnosis when a child presents with recurrent co-morbid conditions such as chronic sinusitis or persistent middle ear disease.

Rhinosinusitis in children

Clinical practice guidelines for the management of acute bacterial rhinosinusitis in children were published by the American Academy of Pediatrics in 2001. Changes in the antibiotic susceptibility patterns for the common pathogens causing both acute and chronic rhinosinusitis warrant a reevaluation and update of these recommendations. In addition, there was only a very brief discussion of chronic disease in this publication, with the conclusion that the pathogenesis and management of recurrent or prolonged infection were essentially unknown. Although there are still insufficient data in the literature to develop evidence-based clinical guidelines, a careful review of recent literature and the clinical experience of experts who manage pediatric chronic sinusitis are presented in an effort to provide some specific recommendations and to offer practical treatment options. Factors associated with chronic rhinosinusitis should be addressed individually and include environmental pollution, recurrent viral upper respiratory infections, allergic and nonallergic rhinitis, ciliary dyskinesia, cystic fibrosis, immunodeficiency, gastroesophageal reflux, and anatomic abnormalities.

Does gastroesophageal reflux contribute to the development of chronic sinusitis? A review of the evidence

Although recent studies suggest that gastroesophageal reflux disease (GERD) may contribute to a variety of ear, nose and throat and pulmonary diseases, the cause-and-effect relationship for the vast majority remains far from proven. In this article, the evidence supporting a possible causal association between GERD and chronic sinusitis has been reviewed. The evidence would suggest that: (i) a higher prevalence of GERD and a different esophagopharyngeal distribution of the gastric refluxate occurs in patients with chronic sinusitis unresponsive to conventional medical and surgical therapy compared to the general population; (ii) a biologically plausible pathogenetic mechanism exists whereby GERD may result in chronic sinusitis; and (iii) clinical manifestations of chronic sinusitis respond variably to antireflux therapy. While these findings suggest that GERD may contribute to the pathogenesis of chronic sinusitis in some patients, it is apparent that the quality of the evidence supporting each of these three lines of evidence is low and therefore does not conclusively establish a cause-and-effect relationship. A number of unresolved issues regarding prevalence, pathophysiological mechanism, diagnosis and treatment exist that deserve further investigation in order to solidify the relationship between GERD and chronic sinusitis. In conclusion, given the possible relationship between GERD and chronic sinusitis, until more convincing data are available, it may be prudent to investigate for GERD as a potential cofactor or initiating factor in patients with chronic sinusitis when no other etiology exists, or in those whose symptoms are unresponsive to conventional therapies.

Long-Term Follow-Up for Children Treated With Surgical Intervention for Chronic Rhinosinusitis

OBJECTIVES/HYPOTHESIS

The goal of this study is to retrospectively compare the long-term, 10 year, outcomes of surgical versus medical management of young children with chronic rhinosinusitis.

STUDY DESIGN

This is a retrospective, age-matched, cohort outcome study performed at a tertiary-care hospital.

METHODS

Two groups of young children (2-5 yr old) with chronic rhinosinusitis were treated with endoscopic sinus surgery or medically managed and evaluated 10 years after their initial therapy. Of the 131 eligible patients, 67 could be located and consented to participate in the study. Six symptoms (day cough, night cough, irritability or crankiness, headaches, nasal airway obstruction, and purulent rhinorrhea) were used to assess the outcome of their treatment.

RESULTS

Children undergoing endoscopic sinus surgery had more significant disease as noted on the computed tomography (CT) scans. Their symptom severity, however, was similar. When individual symptoms were compared, there were no statistically significant differences between the surgically and medically managed groups. When the mean was controlled for baseline symptom severity and CT severity, there was statistical improvement in nasal airway obstruction and decreased rhinorrhea. There was a trend toward improvement in cough, but this was not statistically significant. Parenteral assessment of improvement (change) in symptoms (P = .001) and their degree of satisfaction with treatment (P = .005) was significantly higher in the surgically managed group.

CONCLUSIONS

Children who have chronic rhinosinusitis improve in their symptoms of nasal airway obstruction and purulent discharge if they undergo surgery. Parents of young children with chronic rhinosinusitis appear to be more satisfied with the outcome of surgical management than medical management when assessed 10 years later.

Pediatric functional endoscopic sinus surgery: frequently asked questions

Pediatric endoscopic sinus surgery is a controversial procedure that has evolved considerably over the past 2 decades. We present a current review of the literature regarding the treatment of children with refractory sinusitis with a focus on the use of endoscopic sinus surgery. Preoperative evaluation, surgical technique, postoperative care, and unusual applications are discussed.